Philippine Clinical

Practice Guidelines for the

Management of Gout
(2009)

Philippine Rheumatology Association

Rm 1408 Cathedral Heights Bldg Complex, St. Luke’s Medical Center
E. Rodriguez Sr. Avenue, Quezon City 1002
Telephone No: (+632) 726 8875
Email: pra@pacific.net.ph
Website: http://www.philippinerheumatology.org
 Gout
Philippine Rheumatology Association
Rm 1408 Cathedral Heights Bldg Complex, St. Luke’s Medical Center
E. Rodriguez Sr. Avenue, Quezon City 1002
Telephone No: (+632) 726 8875
Email: pra@pacific.net.ph
Website: http://www.philippinerheumatology.org

Officers and Board of Directors (2008-2010)

President Caroline G. Arroyo, MD
Vice-President Inocencio P. Alejandro, MD
Secretary Bernadette Heizel M. Reyes, MD
Treasurer Eric Jason B. Amante, MD

Board of Directors Leonila F. Dans, MD

Manuel Emerson Donaldo, MD
Jose Paulo P. Lorenzo, MD

Immediate Past President Evelyn O. Salido

75
Gout
Algorithm on the management of a patient with uncomplicated gout

Panel A:
1 GENERAL APPROACH
Patient with
hyperuricemia:
Males >7 mg/dl (0.42 mmol/L)
Females >6 mg/dl (0.36 mmol/L)

2 3 4 5

Any joint pain and Y Y Is there acute Y Go to Panel B

Is it Gout1? arthritis?* (Acute Gouty Arthritis)
swelling?

N N N

6 7
8
Treat as asymptomatic
hyperuricemia Diagnose cause
Go to Panel C
• Correct modifiable risk of joint pains /
(Intercritical and
factors2 swelling and treat
Chronic Gout)
• Do not routinely start accordingly
Allopurinol

1
1977 American College of Rheumatology Criteria for Acute Arthritis of Gout*
A. Monosodium urate (MSU) monohydrate microcrystals in joint fluid during attack, or
B. Tophus proved to contain urate crystals by chemical means or polarized light microscopy, or
C. The presence of 6 of the following 12 clinical, laboratory, and x-ray findings:
1. More than one attack of acute arthritis
2. Maximum inflammation developed within 1 day
3. Monoarthritis attack
4. Redness observed over joints
5. First metatarsophalangeal (MTP) joint painful or swollen
6. Unilateral first metatarsophalangeal joint attack
7. Unilateral tarsal joint attack
8. Suspected tophus
9. Hyperuricemia
10. Asymmetric swelling within a joint on x ray
11. Subcortical cysts without erosions on x ray
12. Joint fluid culture negative for microorganisms during attack

*Bacterial arthritis should always be considered as differential diagnosis in acute monoarthritis. In cases
where bacterial arthritis and acute gout co-exist, treatment should therefore be directed to both.

76
 Gout

Patient with
acute gouty arthritis Panel B:
Acute Gouty Arthritis

9
• Identify and treat precipitants3 of gout flare.
• Do NOT start allopurinol .
• If the patient is already taking allopurinol,
do not change its dose.
• Ice compress (20 mins 4x/day up to one
week)

10 11
• Refer to rheumatologist
Any contraindications • Start Prednisone 30 mg single dose
Y
to colchicine/ NSAID/ on day 1, reduce dose by 5 mg daily
COX-2 selective and discontinue by day 7
inhibitor? • Intravenous or intra-muscular
steroids are options

12 13 14
• Discontinue NSAID/
Colchicine 0.5 mg/tab COX-2 Inhibitor/
1 tab TID –QID ± On Day 7, Is arthritis Y Steroids
NSAID/COX-2 selective resolving? • Start or adjust
Inhibitor ± analgesic Colchicine 0.5 mg/tab
1 tab BID6

15

• Review adherence to meds 8

• Recheck if precipitants Go to Panel C
have been adequately (Intercritical and
treated Chronic Gout)
• Refer to rheumatologist

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Gout
8

Patient with
INTERCRITICAL/
CHRONIC GOUT Panel C:
Intercritical and
Chronic Gouty Arthritis
16
• Start Colchicine 0.5 mg/tab
1 tablet BID
• Prescribe lifestyle
modifications4
• Correct modifiable risk
factors

17 18 19

Is there an Y Is crea Y REFER TO

INDICATION5 to clearance
RHEUMATOLOGIST/
start Allopurinol? <80 mL/minute?
NEPHROLOGIST

N N
20 21

• Instruct patient on • Baseline crea, uric acid

colchicine use to avert
flare
• Monitor/ observe for
indications to start
allopurinol
every 1-3 months & ALT
(SGPT) every 6 months
• Start Allopurinol at 50-
100 mg once daily, to
be titrated by 50-100 mg
every 2-4 weeks

22 23 24

On periodic • Maintain on allopurinol

monitoring, is Y Any flare in Y and colchicine
SUA between visits? • Check lifestyle
<6 mg/dl? • Check adherence to
2
Risk Factors frequently found in medications
association with hyperuricemia
A. Dyslipidemia • REFER TO
B. Obesity N RHEUMATOLOGIST
C. Metabolic Syndrome
D. Congestive Heart Failure 25
E. Psoriasis
F. Malignancies • Maintain allopurinol
N • May discontinue
3
Known precipitants of gout flares colchicine
Stress
Hospital admission or surgery • Continue periodic
Infection monitoring of SUA,
Dehydration crea
Drugs/ Medication (aspirin <1 g/day,
pyrazinamide, ethambutol, diuretics,
etc)
Irregular intake of urate lowering 26 27
medications
4
Lifestyle modifications that • Review the diagnosis
should be prescribed to all Has allopurinol Y of GOUT
patients with gout 300 mg/day • REFER TO
A. Low to moderate purine diet been used?
B. Intake of more fluid (at least 2 RHEUMATOLOGIST
L/day if without contraindication)
C. Avoidance of alcoholic N
beverages 28
D. Maintenance of appropriate
body mass index
E. Engagement in low-to-moderate • Continue titration of
aerobic exercises at least 45
minutes per day 4 times a week allopurinol
• Maintain colchicine
5
Indications for starting urate
lowering therapy
Recurrent arthritis, at least 2
episodes
Presence of tophaceous deposits
Radiographic evidence of chronic
gout
Recurrent uric acid nephrolithiases

78

Philippine Clinical Practice Guide-
lines for the Management of Gout
Abstract
Objective:
Gout is the most prevalent form of arthritis afflicting Filipi-
nos. The diagnosis and overall management need further
improvement especially among medical practitioners.
Our study aims to develop evidence-based guidelines
for general medical practitioners on the management of
uncomplicated gout with the overall goal of improving the
standard of care of patients with gouty arthritis.
Methodology:
The Technical Review Committee (TRC) of the Philippine
Rheumatology Association (PRA) Gout Special Interest
Group (SIG) conducted a literature search relating to
management issues on all phases of gout from years
1980 to 2007 using databases including Medline, Ovid,
Lilacs, Cochrane Central Register of Controlled Trials
(CENTRAL). The GRADE system in rating quality of
evidence and strength of recommendation was used.
A multidisciplinary panel voted and approved the final
recommendations during an en banc meeting.
Results:
Nine recommendations for the management of uncompli-
cated gouty arthritis were developed based on evidence
from the literature and consensus among experts and
key stakeholders. Concerns regarding the initiation and
maintainance of urate lowering therapy, target serum uric
acid levels, treatment of acute gout, lifestyle and dietary
modifications, comorbidities associated with gout such
as cardiovascular disease were addressed.
INTRODUCTION
Gout is the most prevalent form of arthritis among the
Filipinos. The prevalence of gout is 1.6% (1), a distinc-
tive uptrend compared to 1991 when the prevalence was
0.5% (2), and in 1997 when the prevalence was 0.13%
(3). Despite known quality indicators for treatment of
gout (4), there is poor adherence of physicians to these
indicators (5). Interestingly, inappropriate management
of gout is a frequent occurrence even with physician
consultation (6).
The Philippine Rheumatology Association (PRA) sought
to establish evidence-based guidelines with the goal of
improving the standards of care for patients with gout.
It is intended to assist medical care providers in making
decisions on the care of these patients based on the
best available evidence. Guidelines were specifically
sought to address the following issues: to assess the role,
safety and effectiveness of available therapies including
colchicine, corticosteroids, allopurinol; to establish the
role of non-pharmacologic measures including dietary
modification, alcohol cessation, ice compress; to define
the importance of addressing hyperuricemia; to address
the role of other hypouricemic agents such as losartan
and fenofibrate; to emphasize cardiovascular and renal
co-morbidities associated with uncontrolled gout and
hyperuricemia. Issues related to the diagnosis of gout
and management of complicated cases of gout are
not included in this guideline. The full-length text of the
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Gout
guidelines can soon be found on www.philippinerheu-
matology.org.
METHODOLOGY
The PRA Gout Steering Committee convened a technical
review committee to search for and grade the available
evidence related to the management of all phases of
gout.
A search for studies published in English between 1980
and 2007 was done: systematic reviews, meta-analysis,
randomized controlled trials (RCTs), open label trials,
cohort studies on general population, and case reports
on different phases of gouty arthritis. Authors of irretriev-
able published articles were contacted. Full articles and
abstracts were appraised.
The following electronic databases used included:
PUBMED, METACRAWLERS, GOOGLE SCHOLAR,
OVID, MEDLINE, Cochrane Central Regions of Con-
trolled Trials (CENTRAL), the Cochrane Library Issue
3, 2004, LILACS. All related reference lists of retrieved
trials/studies were likewise hand-searched. The following
search terms were used: asymptomatic hyperuricemia,
hyperuricemia, allopurinol hypersensitivity, allopurinol
hypersensitivity syndrome, allopurinol, metabolic syn-
drome, cardiovascular events (congestive heart failure,
hypertension, stroke), diabetes mellitus, renovascular
events (end stage renal disease), purine diet, gout/gouty
arthritis, losartan, fenofibrate, colchicine, non-steroidal
anti-inflammatory drugs (NSAID), selective cyclo-
oxygenase 2 (COX-2) inhibitors, tophi, tophaceous gout,
intra-articular/oral/systemic corticosteroid/glucocorticoid.
Data abstraction was performed independently by at
least 2 separate investigators. Disagreements were
settled through discussions. The GRADE system (7,8)
was utilized in evaluating the quality of evidence and
strength of recommendation. Panel members based
their recommendations on the merits of each evidence,
expert opinion, and local applicability and affordability of
treatment approaches.
Recommendations were then presented to a multidis-
ciplinary panel comprised of representatives from the
Department of Health, and nine other medical societies
(Philippine College of Physicians, Philippine Society of
Nephrology, Philippine Pharmacists Association, Philip-
pine Heart Association, Philippine Society of Endocrinol-
ogy and Metabolism, Philippine Academy of Family Physi-
cians, Nutritionist-Dietitian Association of the Philippines,
and Philippine Academy of Rehabilitation Medicine), and
a patient with gout. During an en banc meeting, nominal
group technique was employed. Panel members cast
their votes to finalize the recommendations.
RESULTS
Nine recommendations were defined by the panel
(Table 1).
Phase 1: Asymptomatic Hyperuricemia
Hyperuricemia is defined as serum uric acid (SUA)
level exceeding the limit of urate solubility in the
plasma, which is 7 mg/dl (416 umol/L) in men and
6 mg/dl (357 umol/L) in pre-menopausal women.
Asymptomatic hyperuricemia is defined as hyperuri-
cemia in the absence of gouty arthritis and uric acid
79
Gout
nephrolithiasis The prevalence of hyperuricemia is
37.8% in males and 18% in females (1).
Hyperuricemia is a central feature of gout but does not
inevitably and absolutely cause it. The development
of gout seems to be directly related to the level of
hyperuricemia however it is not absolute. The cumu-
lative incidences of gout up to 5 years are increased
in direct relation to elevated levels of SUA (9,10).
Hyperuricemia is also associated with hypertension
(11,12,13), obesity (12), and albuminuria in the pres-
ence of renal disease (14). One prospective study did
show that allopurinol treatment may result in improve-
ments in blood pressure and creatinine clearance but
not in proteinuria; however, this study included patients
with normal renal function and allopurinol dose was not
specified (15). In another trial involving patients with
chronic kidney disease, allopurinol treatment resulted
in improvements in renal disease but without significant
improvements in hypertension and proteinuria (16).
Further studies are needed to confirm the benefit of
allopurinol in decreasing cardiovascular and renal risks
in the general population.
The relative risks (RR) for incident gout and hyperuri-
cemia were significantly increased with intake of meat,
seafood, alcohol especially beer and spirits (17-20).
Low to moderate purine diet may reduce SUA and
risk of gout while moderate consumption of purine-
rich vegetable, low fat dairy products, low fat-yoghurt
were not associated with increased risk of gout (18).
High protein intake may increase risk of hyperuricemia
(19).
The expert panel further recommended low impact
and aerobic exercises at least 45 minutes 4 times a
week, intake of at least 8 glasses of water a day, and
maintenance of appropriate BMI (21).
Phase 2: Acute Gouty Arthritis
Acute gouty arthritis is defined in accordance with
the 1977 American College of Rheumatology (ACR)
criteria for the classification of acute attack of primary
gout (22).
There is no evidence demonstrating benefit with a hi-
erarchal order in the use of medications for acute gout.
The Philippine guidelines recommend that the choice
of drug for acute gouty arthritis be individualized taking
into consideration drug efficacy, safety, and cost.
Studies comparing indomethacin with other NSAIDs
have shown comparable efficacy in reducing pain
(23-25). Etoricoxib, a selective cyclooxygenase—2
inhibitor, is also effective but with less gastrointestinal
adverse events (26). “Short course oral steroids” is
defined as 30 mg oral prednisone tapered off over
6 days. Corticosteroids are useful for patients who
have contraindications to therapy with NSAIDs (27,
28). Parenteral corticosteroids may be used among
those who cannot take oral corticosteroids. Colchicine
hastens the resolution of an acute gout attack (29).
However due to significant gastrointestinal toxicity,
the expert panel recommends limiting colchicine to
0.5mg/tab 1 tab BID-QID. Ice compress along with
corticosteroids and colchicine is also beneficial (30).
80
Phases 3 and 4: Intercritical Gout and Chronic
Tophaceous Gout
Intercritical Gout, referred to as “interval gout”, applies
to the asymptomatic periods between gouty attacks.
Chronic Tophaceous Gout (CTG) occurs in untreated
gouty arthritis, characterized by persistent low grade
inflammation of joints with sporadic flares. Joint de-
formities seen are due to deposition of massive urate
crystals forming visible tophi (29).
ULT is indicated in the following situations: recurrent
attacks, radiographic changes, tophaceous deposits,
renal insufficiency, nephrolithiases (26). Likewise,
individuals with high serum urate (>13 mg/dl) even
without clinical signs of gout and high renal urate ex-
cretion should be candidates for ULT to prevent uric
acid nephrolithiases (31).
There is considerable data showing a direct benefit in
lowering SUA on the course of gout. Fifty-six percent
of patients who achieved SUA <6 mg/dl had depletion
of urate crystals from their knee joints and experienced
less gout flares annually compared to patients unable
to achieve this target (32). In a review of 267 patients
followed up for 3 years, infrequent gouty attacks were
associated with reduced SUA concentrations (33).
SUA levels between 4.6–6.6 mg/dl is associated with
fewer gout attacks (34) and faster rate of reduction of
size of tophi (35). Tophaceous deposits were persist-
ent in 37% of those whose urate values remained
>6 mg/dl (35). SUA >6 mg/dl is associated with 59%
higher chances of gout flare (32).
Lowering SUA to <6 mg/dl has likewise shown reduc-
tion of tophi size (35). A prospective study revealed
an inverse relationship of SUA levels and rate of tophi
reduction (32). Although “normal” ranges of SUA levels
differ among, laboratory facilities across the country,
due to lack of standardization, optimal SUA levels of
gout patients should be kept at <6mg/dl.
Allopurinol is a xanthine oxidase inhibitor considered to
be the cornerstone of the clinical management of gout
and other conditions associated with hyperuricemia. It
is used in both urate overproducers and underexcre-
tors. It is the preferred urate-lowering drug in several
countries (36, 37) and is the only drug available in
this class in the Philippines. It has been found to have
the lowest incremental cost-effectiveness ratio (38).
Despite its widespread use, there is a dearth of clini-
cal trials addressing its long term efficacy and safety
for gout. Data from randomized clinical trials showed
that allopurinol given at a daily dose of 200–600 mg
for 12-30 months reduced SUA levels by 3.16 to 4.8
mg/dl with consequent reduction in gout flares and
resolution of tophi in some patients (39-40). Additional
benefits on renal function among chronic gout patients
revealed preserved or improved creatinine clearance
after 12-24 months of therapy (39).
Most clinical studies advocate continuous use over
intermittent use of urate-lowering therapies. SUA rise
rapidly to pretreatment levels after drug discontinua-
tion with recurrence of gout flares and tophi (41-42).
One small prospective 5-year follow-up study of gout
suggested intermittent therapy could be offered to
patients with good SUA control (43).

Recent studies have evaluated the adjunctive benefits
of fenofibrates and losartan among patients with gout.
In the absence of large trials, these may be considered
for the treatment of concomitant dyslipidemia and
hypertension among gout patients. Other uricosuric
agents (sulfinpyrazone, benzbromarone and probene-
cid), are not being dispensed locally. New drugs are
still undergoing clinical trials. Febuxostat, an oral non-
purine selective inhibitor of xanthine oxidase, as of
May 2008 has been approved for use in the European
Union, and is currently undergoing further evaluation in
the United States by the Food and Drug Administration
(FDA). PEG-uricase, a recombinant mammalian urate
oxidase, also shows promise in treating gout-related
hyperuricemia.,
Conclusions
We have developed the first clinical practice guidelines
in the Philippines for management of uncomplicated
gouty arthritis based on best available evidence and
best clinical practice. Nine key recommendations were
extensively evaluated. Updates in management issues
will be integrated as deemed necessary in the next 3 or
more years.
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81
Gout
Table 1.

Philippine Rheumatology Association Guidelines for the management Level of Evidence

of the different phases of Gout
Phase 1: Asymptomatic Hyperuricemia
1. In the general population, asymptomatic hyperuricemia should not be routinely treated C
with allopurinol. Well-known associated risk factors of hyperuricemia, ie. dyslipidemia,
obesity, metabolic syndrome, psoriasis, malignancies, congestive heart failure, should
foremost be addressed.
2. Lifestyle changes recommended include the following:
Adherence to animal or vegetable protein diet as well as intake of dairy products is C
recommended.
Avoidance of a high meat and seafood diet and alcoholic beverages most especially
beer should be prescribed.
Low impact and aerobic exercise at least 45 minutes 4 times a week, intake of at least C, expert opinion
8 glasses of water a day, and maintenance of appropriate BMI, are likewise advised.
Phase 2: Acute Gout
3. In the absence of contraindications , i.e. gastrointestinal ulcers or renal impairment,
the use of colchicine, traditional non-steroidal anti-inflammatory drugs (NSAIDs),
OR selective cyclo-oxygenase 2 (COX-2) inhibitors is recommended for the treatment
of acute gouty arthritis.
The expert panel recommends that colchicine should not exceed 4 tablets in divided
doses per day.
Prednisone, initially at 30 mg and rapidly tapered over 6 days, can be given as
alternative if colchicine, traditional NSAIDs or COX-2 inhibitors are contraindicated or
not tolerated by the patient.
Absence of response after a week should prompt reevaluation of the diagnosis and
referral to a rheumatologist.
4. Ice compress is recommended in combination with pharmacologic agents for relief of
joint pain and swelling of acute gouty arthritis.
Phases 3-4: Intercritical Gout and Chronic Tophaceous Gout
5. Serum uric acid (SUA) level should be reduced to and maintained at <6 mg/dl
(0.36 mmol/L). B
6. Continuous long term therapy with allopurinol is advised to achieve a target serum
uric acid level of <6 mg/dl.
7. Allopurinol should be started at 100 mg/day 2 weeks after the pain and swelling of gouty C
arthritis has subsided. The dose is titrated by 50-100 mg/day every 2 to 4 weeks to
achieve serum uric acid <6 mg/dl. The maximum dose of allopurinol is 300 mg/day.
Referral to rheumatologist is recommended if SUA persistently remains >6 mg/dl
despite maximum dose of allopurinol. SUA and serum creatinine should be periodically
monitored.
8. Colchicine should be used at 0.5 mg/tab OD – BID to prevent gout flares when initiating A
allopurinol. This should be maintained for 3-6 months from the last occurrence of gout
flare and after the optimal SUA target is achieved. In the event that adverse events like
diarrhea occur, a lower dose of colchicine should be used. NSAIDs should not be used
for prevention of gout flares.
9. Dietary modification (to promote weight loss) and avoidance of alcohol should be
prescribed. B
Low impact exercises (walking, biking, swimming, ballroom dancing) may also be
advised. C

A - high level of evidence; B - moderate level of evidence; C - low level of evidence

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 Gout
Panelists
Arroyo C (PRA), Barba M (PRA), Lucero A (PRA), Saguil-
Sy R (PRA), Torralba TP (PRA), Alvarez V (PSHP),
Calalay E (patient), De Castro J (PARM) Dimacali CL
(PSN), Feliciano E (NDAP), Fojas M (PSEM), Joves P
(PAFP), Reyes E (PHA/PCP), Vinluan RM (DOH)

Technical Review Committee Members:

Li-Yu J1, Salido EO2, Manahan S3, Lichauco JJ4, Lorenzo
JP3, Torralba KT5, Raso AA6, Roberto LC6, Santos Estrella
P4, Maceda LM7 in behalf of the Philippine Rheumatol-
ogy Association
1
Assistant Professor, Faculty of Medicine and Surgery, University of Santo
Tomas, Philippines
2
Clinical Associate Professor, University of the Philippines College of
Medicine, Philippines
3
Section of Rheumatology, Department of Medicine, University of the
Philippines, Philippines
4
Assistant Professor, St. Luke’s College of Medicine-William H. Quasha
Memorial, St. Luke’s Medical Center, Philippines
5
Assistant Professor, Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
6
Section of Rheumatology, Clinical Immunology, and Osteoporosis,
Department of Medicine, University of Santo Tomas, Philippines
7
Section of Rheumatology, Department of Medicine, St. Luke’s Medical
Center, Philippines

Acknowledgment
The Steering Committee would like to thank Dr. H Ralph
Schumacher Jr for providing helpful comments on the
contents.

Address correspondence to:

Julie Li-Yu, MD
Philippine Rheumatology Association
Rm 1408 Cathedral Heights Bldg Complex,
St. Luke’s Medical Center, E. Rodriguez Sr. Avenue,
Quezon City 1002,
Email: pra@pacific.net.ph
julieliyu@tri-isys.com
PRA Contact number: (+632) 726 8875

Disclosures

JLY serves as consultant to Novartis and trial investiga-

tor for Pfizer. EOS and JJL serve as trial investigators
for Pfizer. Other members of TRC have nothing to
disclose.

www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 83

Gout
Recommended Therapeutics
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class. For drug information, please refer to the Philippine
Drug Directory System (PPD, PPDr, PPD Text, PPD Tabs).

ANALGESICS
Uricosurics
Allopurinol
Allomaron
Allurase
Drugmaker's Biotech Allopurinol
Llanol
Lopric
Prinol
Purinase
Zyloprim
Benzbromarone
Allomaron
Colchicine
Rhea Colchicine

NSAIDs
Indometacin
Drugmaker's Biotech Indomethacin
Infree
Vigel Cream
Coxibs
Etoricoxib
Arcoxia/Arcoxia AC

HORMONES AND RELATED DRUGS

Adrenocorticosteroid Hormones
Prednisone
Drugmaker's Biotech Prednisone
Prednisone Organon
Prolix
Qualisone

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